Provider Demographics
NPI:1619483880
Name:COOPER, MICHAEL ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 N STATE ST
Practice Address - Street 2:
Practice Address - City:HAMPSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60140-9687
Practice Address - Country:US
Practice Address - Phone:847-683-1300
Practice Address - Fax:847-683-1300
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-23
Last Update Date:2017-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-019095122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist